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What You Need to Know About Claims Scrubbing

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The speed at which medical claims are processed is a vital part of the medical billing process in the United States. If the claim goes through quickly, it can save the patient, provider, and insurer time, money, and frustration. This is where we enter claims scrubbing into the equation. Thorough claims scrubbing is a significant step that will determine whether the claim goes through the first time or not. Whether you are seeking or providing healthcare, it is important to understand what claims scrubbing is and how it factors into the medical billing process.

What Is Claims Scrubbing?

Many steps go into providing and receiving healthcare in the United States. Most medical professionals spend years studying medicine, without spending significant amounts of time learning about other parts of the healthcare industry. This lack of understanding creates complications in the billing process. Though providing the actual medical care is the most important part of the service, the medical billing process is also vital.

To receive payment after providing a patient with medical care, the insurance company needs to receive a claim for the care. Getting a claim accepted by the insurance company is not automatic. Many people assume having insurance means their treatment is covered and do not realize how much goes into a claim. Claims scrubbing is the part of the process that ensures there are no mistakes in the claim that would lead the insurance company to deny it. Third-party healthcare providers often offer this service, as opposed to the medical practice that provided the care. The benefits of claims scrubbing include:

  • Cleaner claims
  • Faster payment
  • Fewer denials
  • Less work
  • More cash flow

Thorough claims scrubbing is advantageous for the medical practice and the patient, making the entire medical billing process significantly easier.

Importance of Claims Scrubbing

Claims scrubbing is a necessary part of the medical billing process. It saves time, money, and significant frustration. During claims scrubbing, many pieces of data from the claim go under review
and analysis, including:

  • Patient and provider data
  • Insurer data
  • Medical necessity
  • Procedures the medical professional performed to reach the diagnosis or treatment
  • Age and gender specific procedures
  • Data about Medicare, Medicaid, and other healthcare programs

If a medical practice continuously fails to submit clean claims, the practice is likely to lose patients and, therefore, revenue. Some of the common issues that may prevent an insurance company from accepting a claim include:

  • CPT code is invalid for the date of service
  • Procedure is missing a diagnosis code
  • Diagnosis code is not valid
  • Member is not effective on the date of service
  • Member ID is not valid
  • Inpatient claim is missing an admission date

Almost any mistake or misinformation on a claim can cause an insurance company to reject it. Even small mistakes like a misspelled name or wrong birthdate will cause the claim to be sent back.

Coding in the Medical Claims Process

The necessary information which must be on a claim is extensive because the insurance company needs to fully understand the situation to determine whether it should accept or deny the claim. In an effort to make the process faster and easier, the medical billing community relies heavily on coding. Using codes acts as a shortcut and prevents professionals from needing to write out every detail for each patient. Explaining each piece of information separately wastes large amount of time and takes medical professionals away from being able to pay attention to the patient. Instead of writing out the diagnosis or type of treatment, they can use a single set of numbers and the insurance company will understand the situation. It standardizes the process.

The significant downside of using codes is that it introduces a large margin for error. All that needs to occur is to enter a single number incorrectly for the insurance company to deny the entire claim. There are more than 13,000 diagnosis codes and 3,000 procedure codes that the medical community uses. Along with diagnosis and procedure codes, there are thousands more HCPCS and CPT codes. All claims must also comply with the rules and regulations of HIPAA. To increase the potential for mistakes, all of the codes are being continually changed and updated.

The number of combinations for medical codes is overwhelming and, because of this, a high chance that an error will occur with the code. If this happens, the insurance company may deny the entire claim and the process will need to begin again, expending even more time and effort.

The large margin of error in coding increases the importance of claims scrubbing. People do not have the time or focus to thoroughly check over each claim, especially considering how many claims are submitted to insurance companies every day. Effective claims scrubbing will identify any coding inaccuracies before sending the claim off, providing the opportunity to fix the error. Fixing a mistake before sending the claim takes significantly less time than submitting a claim, waiting for the insurance company to decide about it, and reviewing the claim after its return.

Electronic Claims Scrubbing

Years ago medical professionals needed to manually check over the information on every claim before submitting it the insurance companies. Some medical providers still do claims processing this way, but most have turned to electronic billing services. To save medical providers from having to manually scrub claims, there are companies that can perform automatic claims scrubbing.

The companies act as a mediator between practices and insurance companies, making the medical billing process easier for everyone involved. The claim is run through software that checks for any errors or inaccuracies before sending it to an insurance company. Using electronic claims scrubbing saves a significant amount of time and prevents medical practices from needing to devote precious manpower to tedious and meticulous work such as reviewing the information on medical claims. It ensures that medical professionals do not need to worry about the technicalities of claims processing and can spend time focusing on the most important part of the healthcare system: the patients.




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